Reporting Periods in 2013

Full Year (January 1, 2013 – December 31, 2013) – eligible professionals (EP) whose PQRS quality measure information is successfully submitted and satisfies the criteria for successful reporting may earn an incentive payment equal to 0.5% of their total allowed Part B allowed charges furnished during the entire year.

Measure Groups Registry Reporting Only:Half Year (July 1, 2013 – December 31, 2013) –Available only for measure group reporting using registries. Eligible professionals whose PQRS quality measure information is successfully submitted and satisfies the criteria for successful reporting may earn an incentive payment equal to 0.5% of their total allowed Part B allowed charges furnished only during the reporting period, July – December 2013.

Reporting Options in 2013

To participate in the 2013 PQRS, individual EPs may choose to report information on individual PQRS quality measures or measures groupsvia four ways: (1) to CMS on their Medicare Part B claims; (2) to a qualified PQRS registry; (3) to CMS via a qualified electronic health record (EHR) product; or (4) via the Group Practice Reporting Option. Individual EPs who meet the criteria for satisfactory submission of PQRS quality measures data via one of the reporting mechanisms above for services furnished during a 2013PQRS reporting period will qualify to earn a PQRS incentive payment equal to 0.5% of their total estimated Medicare Part B Physician Fee Schedule (PFS) allowed charges for covered professional services furnished during that same reporting period.

Please note, EPs may choose to pursue more than one 2013PQRS reporting option. However, an EP who satisfactorily reports under more than one reporting option will earn a maximum of one incentive payment equal to 0.5% of their total estimated allowed charges for Medicare Part B FFS covered professional services furnished during the longest reporting period for which he or she satisfied reporting requirements

Note: Measures with a 0% performance rate and measures groups containing a measure with a 0% performance rate will not be counted.

  1. Claims-Based Reporting: This is the original PQRI (now PQRS) reporting method achieved when a provider reportsat least threeapplicable individual quality measures or one measures group at or above 50% of the time for the entire calendar year.

Each PQRS measure consists of two major components:

1) A denominator that describes the eligible cases for a measure (the eligible patient population associated with a measure’s numerator)

2) A numerator that describes the clinical action required by the measure for reporting and performance

Each measure’s specification includes a reporting frequency requirement for each denominator eligible patient seen during the reporting period. The reporting frequency is described in the instructions and may be stated as:

  • Report at least once for the specified timeframe
  • Report once for each procedure performed, using date of service
  • Report once for each acute care episode
  • Report each time the patient is seen by an eligible professional

A measure’s performance timeframe is defined in the measure’s description and is distinct from the reporting frequency requirement. The performance timeframe, unique to each measure, delineates the timeframe in which the clinical action described in the numerator may be accomplished. Performance timeframes vary for each measure. Performance timeframes for measures tied to a specific clinical process may be stated as, “once within a given reporting period,” or “most recent.” This means that:

  • The clinical action in the numerator needs to be performed only once during a given reporting period for each patient seen during the reporting period.
  • PQRS Quality-Data Codes (QDCs) need to be reported only one time for each patient by each eligible professional caring for the patient who has chosen to report that measure during the reporting period.
  • If the measure calls for a clinical test result, then the most recent test result only needs to be obtained, assessed, and reported one time per reporting period. A test does not need to have been performed within the reporting period, nor does it need to have been performed by the same eligible professional.

QDCs are HCPCS codes comprised of specified CPT Category II codes and/or G-codes that describe the clinical action required by a measure. Clinical actions can apply to more than one condition, and therefore can also apply to more than one measure.

The following principles apply to the reporting of QDCs for PQRS measures:

  • The CPT Category II code(s) and/or G-code(s), which supplies the numerator, must bereported on the same claim form as the payment codes, usually ICD-9-CM and CPTCategory I codes, which supply the denominator.
  • QDCs must be submitted with a line item charge of zero dollars ($0.00) at the time theassociated covered service is performed.
  • The submitted charge field cannot be blank.
  • The line item charge should be $0.00.
  • If a system does not allow a $0.00 line item charge, use a small amount such as$0.01.
  • Entire claims with a zero charge will be rejected. (Total charge for the claimcannot be $0.00.)
  • Quality-data code line items will be denied for payment, but are then passedthrough the claims processing system for PQRS analysis. Eligible professionalswill receive a Remittance Advice (N365) as confirmation that the QDC(s) passedinto the National Claims History file.
  • Multiple eligible professionals’ QDCs can be reported on the same claim using theirindividual NPI.
  • Some measures require the submission of more than one QDC in order to properlyreport the measure.
  • Report each QDC as a separate line item, referencing one diagnosis and including the rendering provider NPI.
  • Use of CPT II modifiers (1P, 2P, 3P, 8P) is unique to CPT II codes and may not be used with other types of CPT codes. Only CPT II modifiers may be appended to CPT II codes. CPT II modifiers can only be used as indicated in the measure specification.
  • Eligible professionals may submit multiple codes for more than one measure on a singleclaim.
  • Multiple CPT Category II and/or G-codes for multiple measures that are applicable to apatient visit can be reported on the same claim, as long as the correspondingdenominator codes are also line items on that claim.
  • The individual NPI of the participating eligible professional(s) must be properly used onthe claim.
  • Claims may not be resubmitted simply to add QDC(s).
  1. Measures Groups Reporting: CMS created measures groups – subsets of PQRS measures that have in common a focus on a particular clinical condition or aspect of care – that allow providers to report on one group of measures, however providers must still report the applicable CPT II or G-code quality data codes for each of the measures in the measures group that are applicable to the patient. Diabetes Mellitus, Chronic Kidney Disease (CKD), Preventive Care, Coronary Artery Bypass Graft (CABG), Rheumatoid Arthritis (RA), Perioperative Care, Back Pain, Hepatitis C, Heart Failure (HF), Coronary Artery Disease (CAD), Ischemic Vascular Disease (IVD), HIV/AIDS, Community-Acquired Pneumonia (CAP), Asthma, Chronic Obstructive Pulmonary Disease (COPD), Inflammatory Bowel Disease (IBD), Sleep Apnea, Dementia, Parkinson’s Disease, Hypertension, Cardiovascular Prevention and Cataracts. The measures groups most applicable to nephrology practice are composed of the following PQRS measures:

Diabetes Mellitus:

Measure Number 1 – Hemoglobin A1c Poor Control in Type 1 or 2 Diabetes Mellitus Measure Number 2 – Low Density Lipoprotein Control in type 1 or 2 Diabetes Mellitus Measure Number 3 – High Blood Pressure Control in Type 1 or 2 Diabetes Mellitus

Measure Number 117 – Dilated Eye Exam in Diabetic Patient

Measure Number 119 – Urine Screening for Microalbumin or Medical Attention for Nephropathy in Diabetic Patients

Measure 163 – Diabetes Mellitus: Foot Exam

Chronic Kidney Disease (CKD):

Measure Number 110 - Preventive Care andScreening: Influenza Immunization

Measure Number 121 – CKD: Laboratory Testing (Calcium, Phosphorus, Intact Parathyroid Hormone (iPTH) and Lipid Profile)

Measure Number 122 – CKD: Blood Pressure Management

Measure Number 123 – CKD: Plan of Care: Elevated Hemoglobin for Patients Receiving Erythropoiesis-Stimulating Agents (ESA)

To select a measures group reporting option via claims, the first step requires that eligible professionals identify their intent to report a measures group by submitting a measures group-specific intent G-code on a claim for covered professional services furnished to a patient enrolled in Medicare Part B PFS. The submission of the intent G-code serves as the indication that an eligible professional is choosing to report on a measures group and will initiate measures group analysis. It is not necessary to submit the measures group-specific intent G-code on more than one claim. If the G-code for a given group is submitted multiple times during the reporting period, only the submission with the earliest date of service will be included in the Physician Quality Reporting analyses; subsequent submissions of that code will be ignored.

G8485: I intend to report the Diabetes Mellitus (DM) Measures Group

G8487: I intend to report the Chronic Kidney Disease (CKD) Measures Group

This measures group can be reported by one of the following patient sample methods:

  • 20 Patient Sample Method — ≥20 unique Medicare Part B FFS (fee for service) patients meeting patient sample criteria forthe measures group.
  • 12 Month Reporting Period – January 1, 2013 – December 31, 2013
  • Available for claims or registry reporting of measure groups
  • 6 Month Reporting Period – July 1, 2013 – December 31, 2013
  • Available only for registry reporting of measure groups
  1. Registry Reporting:This reporting option requires providers to select a registry which has been approved by CMS as a qualified registry for data collection and once or twice yearly data submission. This method is expected to become the preferred method for many providers since they can review the data and add key clinical information regarding the patient at anytime. Additionally, providers DO NOT need to select CPTII codes for registry reporting since the registry performs the measure calculations and performance data is submitted separately from the billing process.

Individual CKD measures and the CKD measure group may be reported via registry.

  • Report on ≥ 3 Individual Measures for 12 months (January 1, 2013 – December 31, 2013) for ≥ 80% of applicable Medicare Part B FFS Patients
  • Report on ≥ 1 Measure Group for 12 months for 12 months (January 1, 2013 – December 31, 2013) for ≥ 20 Applicable Patients for Measure Group (at least 11 must be Medicare Part B FFS Patients) OR report on ≥ 1 Measure Group for 6 months (July 1, 2013 – December 31, 2013) for ≥ 20 Applicable Patients for Measure Group (at least 11 must be Medicare Part B FFS Patients)

The registry-only measures most applicable to nephrology practice are composed of the following PQRSindividual measures: 81-Plan of Care for Inadequate HD in ESRD Patients and 82-Plan of Care for Inadequate PD in ESRD Patients.

  1. Group Practice Reporting Option: A “group practice” under 2013 Physician Quality Reporting consists of a physician group practice, as defined by a single TIN, with 2 or more individual eligible professionals (as identified by individual NPIs) who have reassigned their billing rights to the TIN. This definition of group practice is different from the definition of group practice that was applicable for the 2012 Physician Quality Reporting System, which defined a group practice as 25 or more eligible professionals.

For group practices comprised of 2-24 eligible professionals:

Qualified Registry

  • Group practices report three (3) measures; AND
  • Report each measure for at least 80% of the group practice’s Medicare Part B FFS patients seen during the reporting period to which the measure applies.
  • Measures with a 0% performance rate will not be counted.

For group practices comprised of 25-99 eligible professionals:

Qualified Registry

  • Group practices report three (3) measures; AND
  • Report each measure for at least 80% of the group practice’s Medicare Part B FFS patients seen during the reporting period to which the measure applies.
  • Measures with a 0% performance rate will not be counted.

Web interface

  • Group practices report on all GPRO measures included in the web interface
  • The group practice will need to populate the remaining data fields in the web interface necessary for capturing quality measure information on each of the assigned beneficiaries—up to 218 beneficiaries for each module or preventive care measure
  • If the pool of eligible assigned beneficiaries for any module or preventive care measure is less than 218, then the group practice will need to populate the remaining data files for 100 percent of eligible beneficiaries for that module or preventive care measure
  • For each module and preventive care measure, the group practice must report information on the assigned patients in the order in which they appear in the group’s sample

For group practices comprised of 100 or more eligible professionals:

Qualified Registry

  • Group practices report three (3) measures; AND
  • Report each measure for at least 80% of the group practice’s Medicare Part B FFS patients seen during the reporting period to which the measure applies.
  • Measures with a 0% performance rate will not be counted.

Web interface

  • Group practices report on all Physician Quality Reporting System GPRO quality measures included in the web interface
  • The group practice will need to populate the remaining data fields in the web interface necessary for capturing quality measure information on each of the assigned beneficiaries—up to 411 beneficiaries for each module and preventive care measure
  • If the pool of eligible assigned beneficiaries for any module or preventive care measure is less than 411, then the group practice will need to populate the remaining data files for 100 percent of eligible beneficiaries for that module and preventive care measure For each module and preventive care measure, the group practice must report information on the assigned patients in the order in which they appear in the group’s sample

Group practices consisting of 100+ eligible professionals, beginning in 2013 will be subject to the Value-based Payment Modifier. A group practice with 100 or more eligible professionals may avoid a 2015 VBM downward payment adjustment by satisfactorily reporting to avoid the 2015 PQRS payment adjustment.

All group practices participating in the 2013 Physician Quality Reporting System GPRO via the web interface, regardless of size, are required to report on all quality measures grouped into 18 measures (including two composite measures for a total of 22 measures) and seven disease modules: Care Coordination/Patient Safety (Care), Preventive Care, Coronary Artery Disease (CAD), Diabetes Mellitus (DM), Heart Failure (HF), Hypertension (HTN), and Ischemic Vascular Disease (IVD).

PQRS GPRO Self-Nomination

To be considered as a PQRS GPRO, participants must comply with the following requirements:

  • Have billed Medicare Part B on or after January 1, 2012 and prior to approximately October 31, 2012
  • Agree to have the results on the performance of their Physician Quality Reporting System measures publicly posted on the Physician Compare Web site
  • Have technical capabilities, at a minimum: standard PC image with Microsoft® Office and Microsoft® Access software installed; and minimum software configurations
  • Be able to comply with a secure method for data submission
  • Provide CMS access to review the Medicare beneficiary data on which Physician Quality Reporting System GPRO submissions are founded or provide to CMS a copy of the actual data
  • Indication of group practice’s participation in the 2013 eRx Incentive Program with intended reporting method identified and/or request for a hardship exemption from the 2014 eRx payment adjustment
  • Indicate desire to participate in the Physician Quality Reporting System and eRx as individuals or as a GPRO
  • Provide all requested data on the CMS self-nomination website. CMS will issue additional guidance at a later date with information on the specific website for self-nomination.

To be considered for 2013 Physician Quality Reporting GPRO, all group practices must address the above requirements in a self-nomination statement received via the web by October 15, 2013. Group practices must also select their reporting method at the time of self-nomination, and may change this method at any time prior to the October 15, 2013 deadline.

We anticipate that a list of qualified registries will be posted on the CMS website in the summer of 2013.

Note that there are two different self-nomination deadlines for 2013 GPRO. The deadline to self-nominate for PQRS GPRO is October 15, 2013. However, the deadline to self-nominate for eRx GPRO is January 31, 2013. Please see the eRx GPRO requirements for additional discussion on the eRx GPRO program.

  1. EHR Reporting: CMS will accept PQRS quality measures data extracted from a qualified EHR product for a limited subset of 2013 PQRS quality measures. As stated in the 2013 PFS final rule, 51 measures are available for EHR-based reporting in 2013.

Eligible professionals have the following EHR-based reporting options:

1)Submit PQRS quality measure data directly from their EHR system.

Eligible professionals who choose to report on EHR measures must report on a minimum of three measures for Medicare Part B beneficiaries at an 80 % reporting rate to be able to qualify to earn a PQRS incentive payment.

2) Submit PQRS quality measure data extracted from their EHR to a qualified EHR Data Submission Vendor.

The EHR Data Submission Vendor would then submit the PQRS measures data to CMS in the CMS-specified format(s) on the eligible professional’s behalf. Eligible professionals who choose to report on EHR measures must report on a minimum of three measures for Medicare Part B beneficiaries at an 80 % reporting rate to be able to qualify to earn a PQRS incentive payment.

2)Submit quality measure data through the PQRS-Medicare EHR Incentive Program Pilot which uses specific 2012 Physician Quality Reporting EHR measure specifications.

Eligible professionals participating in the Pilot are required to submit information on three core measures. If the denominator for one or more of the core measures is zero, the eligible professional must report on up to three alternate core measures. Eligible professionals must also report on three additional measures available for the Medicare EHR Incentive Program.

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